Information Collection

Department of State Mentor-Protege Program Application

IC 38774 under ICR 201105-1405-005 · OMB 1405-0161.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 1405-0161 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Form DS-4053 Department of State Mentor-Protege Program Application	Form
DS-4053 Mentor-Protege Program Application MP Application .pdf	Form
legalAuthorities.docx Legal Authorities	IC Document

IC Title:

Department of State Mentor-Protege Program Application

Agency IC Tracking Number:

Is this a Common Form? No

IC Status: Modified

Obligation to Respond: Required to Obtain or Retain Benefits

CFR Citation:

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability
Form	DS-4053	Mentor-Protege Program Application	MP Application .pdf		Yes	Yes	Fillable Fileable

Line of Business: Economic Development

Subfunction: Business and Industry Development

Privacy Act System of Records

Title:

FR Citation:

Number of Respondents: 14

Number of Respondents for Small Entity: 0

Affected Public: Private Sector

Private Sector: Businesses or other for-profits

Percentage of Respondents Reporting Electronically: 98 %

table that charts list of burden
	Approved	Previously Approved
Annual Number of Responses for this IC	14	14
Annual IC Time Burden (Hours)	294	294
Annual IC Cost Burden (Dollars)	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Legal Authorities	legalAuthorities.docx	05/05/2011

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.